Chronic Low Back Pain

Why low back pain becomes chronic

Most acute back pain improves substantially within 6 weeks. In some people it persists. This is rarely because ongoing damage is getting worse. Instead, several factors combine:

• Sensitized pain system: after weeks of pain, nerves in the spinal cord and brain amplify signals so normal movement hurts more.
• Deconditioning: avoiding movement weakens and stiffens the back and core.
• Fear and worry: believing that pain means harm leads to guarding and avoidance, which keep pain going.
• Sleep problems, stress and low mood.
• Work factors: job dissatisfaction, heavy lifting without support, and long sick leave.

Doctors call psychological and social contributors "yellow flags." They predict chronic pain better than scan findings.

Causes

Nonspecific (mechanical) low back pain

The large majority. Pain comes from a combination of muscles, ligaments, discs and joints, varies with posture and activity, and has no single identifiable source. See mechanical back pain.

Specific causes

Pain can also be referred from the kidneys, pelvis, aorta or bowel.

Diagnosis

A clinician will ask about the pain pattern, leg symptoms, red flags, work and activity, sleep, mood and beliefs about the pain, and examine the back, hips and nerves (strength, reflexes, sensation and straight leg raise).

Imaging is not routinely recommended. X-rays, CT and MRI often show disc bulges, degeneration and arthritis that are equally common in people without back pain, and finding them does not change treatment for nonspecific pain. Imaging is useful when:

• red flags suggest fracture, infection, cancer or cauda equina syndrome
• surgery or an injection is being considered for sciatica or stenosis
• inflammatory back pain is suspected (MRI of the sacroiliac joints)

Blood tests (CRP, ESR, HLA-B27) help when inflammatory arthritis is suspected.

Treatment

Exercise and physical therapy

Exercise is the cornerstone. No single type is clearly best, so choose what you will keep doing:

• motor control and core exercises
• Pilates, yoga and tai chi
• walking programs and aerobic exercise
• strength training for the back, hips and legs

Start gently, increase gradually, and expect some soreness as you build tolerance. Hurt does not equal harm.

Psychological approaches

• Cognitive behavioral therapy (CBT) and pain reprocessing therapy reduce pain intensity and disability.
• Mindfulness-based stress reduction helps many people.
• Pain education: understanding how pain works reduces fear and avoidance.

Other non-drug treatments

The American College of Physicians recommends trying non-drug treatments first, including spinal manipulation, acupuncture, massage, progressive relaxation, and multidisciplinary rehabilitation. Heat can ease flares.

Medicines

• NSAIDs (ibuprofen, naproxen) for short-term relief, at the label dose, if safe for your stomach, kidneys and heart.
• Duloxetine may help some people, prescribed by a doctor.
• Acetaminophen (paracetamol) has little benefit for chronic low back pain on its own.
• Opioids are not recommended as routine treatment; risks often outweigh benefits.
• Muscle relaxants and gabapentinoids have limited evidence for chronic nonspecific back pain.

Injections and surgery

• Epidural steroid injections can give short-term relief for sciatica, not for back pain alone.
• Radiofrequency denervation helps some people with facet joint pain.
• Surgery (decompression for stenosis or herniated disc, fusion in selected cases) helps leg-dominant nerve pain more than back pain, and is reserved for clear structural problems that fail conservative care.

Living with chronic low back pain

• Stay active and keep working if possible, with adjustments.
• Use pacing: spread activity through the day rather than overdoing it on good days.
• Change position often; avoid long periods of sitting.
• Prioritize sleep and manage stress.
• Make a flare plan: heat, gentle movement, short-term pain relief, and reducing but not stopping activity.
• Stop smoking and maintain a healthy weight.

Frequently asked questions

What causes chronic low back pain?

Most chronic low back pain is nonspecific: a mix of muscle, joint and disc factors plus a sensitized pain system, without a single structural cause. Specific causes include herniated discs, spinal stenosis, spondylolisthesis and inflammatory arthritis. Stress, poor sleep and fear of movement often keep pain going.

What is the best treatment for chronic low back pain?

Exercise and physical therapy are the cornerstone, combined with psychological approaches such as CBT or mindfulness. Spinal manipulation, acupuncture and massage help some people. Medicines play a smaller role, and opioids and surgery are not first-line for nonspecific pain.

Do I need an MRI for chronic back pain?

Usually not. MRI findings such as disc bulges are common in people without pain and do not guide treatment for nonspecific back pain. MRI is recommended if there are red flags, significant nerve symptoms, or if surgery or injections are being considered.

When should I worry about lower back pain?

Seek emergency care for numbness around the genitals, bladder or bowel problems, or new leg weakness. See a doctor promptly for back pain with fever, weight loss, a history of cancer, night pain, or after a fall in older age or with osteoporosis.

Can chronic low back pain go away?

Yes, for many people it improves substantially. Pain often fluctuates, with flares and good periods. Active treatment, especially exercise and approaches that reduce fear and sensitization, helps most people reduce pain and get back to the activities that matter to them.